Norman Regional Hospital Board of Authority Meeting

NORMAN REGIONAL HOSPITAL AUTHORITY Board Meeting October 23, 2023 MINUTES The Norman Regional Hospital Authority met in monthly session Monday, October 23, 2023 at 5:30p.m. in the Norman Regional Porter Board Room. The meeting Agenda was posted October 19, 2023 on the NRHS and City of Norman websites and at the entrance to Norman Regional Hospital. Members Present: Doug Cubberley Joan Greenleaf James Chappel Jerome (Jerry) Weber, Ph.D. Muhammad Anwar, MD Mary Womack Paula Roberts Others Present: Richie Splitt, President & CEO John Manfredo, VP, Chief Operations Officer Brittni McGill, VP, Chief Nursing Officer Keith Minnis, VP, Chief People Officer Elaine Purvis, VP, Chief Strategy Officer Dr. Aaron Boyd, MD, VP & Chief Physician Executive Rick Wagner, VP, Chief Financial Officer Joe Voto, MD, Chief of Medical Staff Dr. James Bond, MD, Chief of Medical Staff Elect Jenny Anderson, Administrative Director, Patient Quality Larry Harden, Administrative Director, Risk & Compliance Maggie Martin, Attorney, Crowe & Dunlevy Ray Leyva, Multimedia & Video Specialist, Media Services Melissa Herron, Director, Integrated Marketing Garrett Fergeson, Manager, Integrated Marketing LeAnn Richardson, Administrative Director, Population Health Tammy Adkins, LPN, NHealth Gavin Nation, OU’s JC Penny Leadership Fellow Jeff Raley, Floyd & Driver Stuart England, Floyd & Driver David Floyd, Floyd & Driver Jill Hogue, Director of Strategic Marketing, Freestyle Creative Kelly Gann, CEO, Freestyle Creative Members Absent: Kevin Pipes Dianne Chambers, MD Recorder: Claudia Todd, Executive Assistant  NRHA Board Minutes 2 October 23, 2023 Agenda Item I. Meeting Called to Order Mr. Cubberley called to order the October 23, 2023, Norman Regional Hospital Authority business meeting at 5:32 p.m. Agenda Item II. Introduction and Recognition of Outstanding Healers A. October 2023 Healer of the Month – Tammy Adkins, LPN, NHealth. Mr. Cubberley introduced LeAnn Richardson, Administrative Director Population Health, to introduce Ms. Adkins to the Board. Ms. Richardson shared Ms. Adkins has been an LPN for 35 years, and 8 of those have been at NRHS. She is the Care Coordinator of the NRHS’s Coordinated Care Plan. She works with healers to ensure they receive the referrals they need, they are happy with the services and providers offered when they require healthcare outside of our health system. The second part of her role is working with NRHS healers who have chronic illnesses. She works with these healers to ensure they have access to their medications, appointments and are following the health plans designed specifically for them to receive the best care possible. She believes this is truly her calling. Ms. Adkins was born and raised in Oklahoma. Her life priorities are family, friends and church. She has 5 children and 10 grandchildren who she enjoys spending time with when she is not outdoors, hiking, camping or fishing. Ms. Adkins heart for caring does not stop at work. She visits and cooks meals for elderly adults at her church, making sure they aren’t lonely and have something nutritious to eat. Ms. Adkins thanked everyone for the honor. She stated she loves her job and has made lifelong friends at NRHS. Mr. Cubberely congratulated and thanked Ms. Adkins on behalf of the Board for her outstanding dedications, professionalism, compassion and positive attitude that continues to make Norman Regional Health System a caring, high-quality health system. Ms. Richardson and Ms. Adkins left the meeting at 5:39pm. B. November 2023 Healer of the Month – Liz Love, Perioperative Admin Support, Same Day Surgery Ms. Love was unable to attend the October 23, 2023 NRHA Board meeting and will be recognized at the Board meeting on November 27, 2023. Agenda Item III. Board Education: Community Engagement/Outreach  NRHA Board Minutes 3 October 23, 2023 Ms. Melissa Herron, Director Integrated Marketing, along with Garret Ferguson, Manager of Digital Media, presented an update on the 2024 community outreach initiatives. With the completion of the Inspire Health implementation, NRHS recognizes a great opportunity to initiate a new, vibrant community awareness campaign. Our objective is to elevate awareness about NRHS’s innovative community services and providers, offer valuable resources, and solidify NRHS as the preferred healthcare provider committed to community health and well-being. To realize these objectives, NRHS will leverage several key tools:  In-depth market research  Strategic advertising on billboards and digital platforms  Website enhancements  Public Relations efforts focusing on the expansion and opening of the HealthPlex With a well-established partnership with two local companies, NRHS will engage in both qualitative and quantitative research. This research will guide our messaging strategy within the community and beyond. During the presentation, Ms. Herron introduced representatives from one of these partners, Ms. Jill Hogue and Ms. Kelly Gann, who offered insights into the approach and goals for 2024. Our aim is to gain insights into community perceptions and aspirations, allowing us to highlight the stories and resources available through NRHS as the community’s preferred healthcare provider. Mr. Leyva left the meeting at 5:55pm. Ms. Hogue and Ms. Gann left the meeting at 6:05pm. Agenda Item IV. Approval of September 25, 2023 Norman Regional Hospital Authority Board Meeting Minutes A. Mr. Cubberley asked for approval of the September 25, 2023 Board Meeting Minutes ACTION TAKEN: Ms. Roberts made the motion to approve the September 25, 2023 Board Meeting Minutes. Mr. Chappel seconded the motion, and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Ms. Womack, Dr. Anwar and Ms. Roberts. Agenda Item V. Performance Update Ms. Jenny Anderson, Administrative Director, Patient Quality, provided an update on Gainsharing Metrics and a CMS Star Ratings update. Ms. Anderson reminded everyone of the Healer Gainsharing metrics approved at the September Board meeting includes: Service Excellence, Team Excellence, Operational Excellence and Clinical Excellence. Next steps towards obtaining these goals include  NRHA Board Minutes 4 October 23, 2023 resuming the Gemba Walks in December 2023 to learn how departments are using the data and developing department level metrics related to our health system strategic imperatives. Additional strategies for obtaining these goals include:  Listen to our customers and exceed their expectations  Drive total quality transformation  Standardize and hardwire processes to achieve drive results  Invest in our healers and enhance our culture of engagement  Expand access to care  Strengthen financial resilience Ms. Anderson reviewed the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) dashboard, highlighting the current 12-month values and the improvement targets. Agenda Item VI. Medical Staff A. Dr. Voto presented the Medical Staff report. He stated the Medical Executive Committee (MEC) met on October 11, 2023. MEC covered a number of topics including – Reflex Testing, Stroke Order Sets, Admit Orders, Utilization Review Plan, Medical Credentialing, Department Committee Reports and Executive Team updates. Agenda Item VII. Patient Quality & Safety Committee A. Mr. Cubberley announced a summary of the Patient Quality & Safety Committee Meeting is included in the board packet. Ms. Greenleaf is available to address questions. Agenda Item VIII. Letter of Resolution for Opioid Grant Application ACTION TAKEN: Dr. Weber motioned to approve the Letter of Resolution for opioid Grant Application. Mr. Chappel seconded the motion and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. Agenda Item IX. Finance Committee A. Mr. Wagner reported the Finance Committee met October 19, 2023. B. Mr. Wagner presented the NRHS Financial report for September 2023: September 2023 Financial Performance  NRHA Board Minutes 5 October 23, 2023  Gross Revenues .................................. (Budget $209,952,021)............ $207,659,277  Net Patient Revenue .............................. (Budget $45,711,851).............. $42,239,674  Total Operating Expenses ..................... (Budget $48,613,823).............. $49,356,460  Total Operating Revenues ...................... (Budget $46,384,058).............. $42,953,829  Operating Income .................................... (Budget $2,229,765).............. ($6,402,631)  Non-Operating Revenues (Expenses) ..... (Budget $1,235,322).............. $(3,142,559)  Excess Revenues over Expenses ............... (Budget $994,443).............. ($9,545,191) Year-to-Date  Operating Income .................................... (Budget $4,776,365)............ ($11,641,810)  Non-Operating Revenues (Expenses) ..... (Budget $3,705,966).............. ($2,140,028)  Excess Revenues over Expenses ............ (Budget $1,070,399)............ ($13,781,838)  Accounts Receivable Days ............................ (Budget 48 Days) .................. 51.3 Days  Days Cash on Hand………………………………………………………….…..91.4 Days ACTION TAKEN: Dr. Weber motioned to approve the September 2023 NRHS Financial Statements. Dr. Anwar seconded the motion. August 2023 Financials were approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. C. Mr. Wagner presented for approval one capital request item totaling $101,709 a. Clinic Imaging Equipment: $101,709 ACTION TAKEN: Dr. Weber made a motion to approve the Capital Equipment Request at a total cost of $101,709 as recommended by the Finance Committee. Ms. Roberts seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. D. Recommend Approval of Line of Credit ACTION TAKEN: Dr. Weber made a motion to approve the Line of Credit as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. E. Recommend Approval of Legal Services Agreement ACTION TAKEN: Dr. Weber made a motion to approve the Legal Services Agreement as recommended by the Finance Committee. Ms. Greenleaf seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts.  NRHA Board Minutes 6 October 23, 2023 Mr. Raley, Mr. England and Mr. Floyd left the meeting at 6:32pm. Agenda Item X. Old Business None. Agenda Item XI. New Business Mr. Cubberley announced Elections for the Board of Trustees Officers will be at the November 27th board meeting. The CEO evaluation will be sent to Trustees in November and will be reviewed at the January 2024 board meeting. Ms. Anderson left the meeting at 6:59pm. Agenda Item XII. Administrative Report Mr. Splitt shared several updates:  As part of NRHS’s High Reliability Organizational (HRO) journey, the Safety, Communication, Operational Risk, Resilience/Burnout and Engagement (SCORE) survey was sent to all healers in October. The survey is designed to provide insights that are both diagnostic and actionable, as well as drive improvement, enhance trust and support organizational learning. The results of this survey provide opportunities in both clinical and non-clinical settings that proactively assess what it feels like to work there and evaluates issues such as safety, teamwork, learning and the quality of leadership. NRHS introduced SCORE because we believe culture lives at a unit level, and this tool helps us understand how our healers feel when they work together in a specific location. The SCORE survey will allow us to generate specific actions to build upon existing cultural strengths, and to address cultural weaknesses and areas of opportunity.  The Adult Wellness and Education Center is scheduled to open on November 13th. There will be a ribbon cutting for the community.  The former CEO of the Oklahoma Hospital Association, Patti Davis, was recognized as the Woman of Year for 2023. Ms. Davis was selected from a group of 50 incredibly taled nominees from across the state. Ms. Davis now servces as the CEO of the LifeCare Member Network.  OHA Connect 2023 will be in November at the Oklahoma City Convention Center. Please contact Claudia to register if you would like to attend.  We recently received two letters from patients’ highlighting great patient care received from our healers. Copies of the letter were shared with trustees.  The Sooner Healthcare Executive association, the state chapter of the American College of Health Executives (ACHE), recently organized an education event that was skillfully coordinated by NRHS’s Joe Mankin, Director of Supply Chain Management. This event delved into the current challenges in healthcare, featuring our esteemed CFO,, Rick Wagner, as a key member of the expert panel. Mr. Wagner provided insightful and impactful contributions, representing NRHS with distinction and expertise.  NRHA Board Minutes 7 October 23, 2023  At the recent LifeCare Board Meeting, discussions continue regarding further development of a Clinically Integrated Network (CIN). This LifeCare CIN is a partnership between member health systems that are collaborating to deliver evidence-based care, improved quality, efficiency, and coordination of care, and demonstrate value to the state of Oklahoma. Ms. McGill shared the Joint Commission visited recently for our Stroke recertification process. They were verify complimentary of the program and we anticipate full reaccreditation in the coming weeks. Mr. Manfredo provided an update on the following:  Construction on the HealthPlex cafeteria  Timelines for estimated completion for all Inspire Health projects  Norman Regional 9 one year anniversary statistics  iPad replacement for trustees Mr. Minnis announced open enrollment for healer benefits for 2024 starts November 1st. The new Earned Wage Access app goes live on November 1st. This app provides our healers the flexibility to access the money they’ve already earned on- demand. It’s not a loan and there’s no interest. Dr. Boyd provide an update on the following:  NHealth provider networking event  The Joint Commission visited the Cancer Care Center as part of the joint venture with OU Health Stephenson Cancer Center Ms. Herron and Mr. Fergeson left the meeting at 7:20pm. Agenda Item XIII. Proposed Executive Session A. Proposed Vote to Convene an Executive Session Pursuant to 25 Okla. Stat. Section 307 B.4. to Discuss with Legal Counsel Pending Internal Peer Review/Credentialing Investigation Regarding the Medical Staff Members/Applicants Listed Below; ACTION TAKEN: Dr. Weber made a motion to adjourn into Executive Session. Dr. Anwar seconded and the motion was approved unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. B. Medical Staff Recommendations Regarding the Medical Staff Members/ Applicants as Listed in XIII.B 1-3 Below. 1. Recommend New Provisional Medical Staff Appointments: a. Clara Tang, MD – OB/GYN – Active b. Lauren White, DO – Pediatrics – Active c. Stephen Kruszka, DO – OB/GYN – Active d. Collin Hall, PA-C – Surgery – Allied Health NRHA Board Minutes 8 October 23, 2023 e. Brock Vorwald, PA-C – Surgery – Allied Health f. Tracey Walker, APRN-CNS – Surgery – Allied Health 2. Recommend Advancement of Medical Staff from Provisional Status: a. Greg Rohde, DPM – Surgery – Active b. Vincent Montgomery, DMD – Surgery – Active c. Mark Moses, MD – Surgery – Active d. Joe Voto, MD – Anesthesia – Active e. Holly Costner, DO – Emergency Medicine – Active f. Ryan Wilson, DO – Emergency Medicine – Active g. Charles Anderson, DPM – Surgery – Consulting h. Ronald “Hal” Bays, APRN-CRNA – Anesthesia – Allied Health 3. Recommended Medical Staff Reappointments: a. Haley Corgan, APRN-CRNA – Anesthesia – Allied Health b. Theresa Yuh, MD – Radiology – Privileges Only c. Shota Yamamoto, MD – Radiology – Privileges Only d. Jeremy Theisen, MD – Radiology – Privileges Only e. Tae Ro, MD – Radiology – Privileges Only f. Artin Aharonian, MD - Radiology – Privileges Only g. Andrew Martin, MD – Radiology – Privileges Only h. Ryan Jean-Baptiste, MD – Radiology – Privileges Only i. James Frencher, MD – Radiology – Privileges Only j. Robert Farrell, Jr. MD – Radiology – Privileges Only C. Request to Adjourn Out of Any Such Executive Session and Return to Regular Session ACTION TAKEN: Dr. Weber made a motion to adjourn out of Executive Session. Mr. Chappel, and the motion was approved unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. Mr. Cubberley noted the Board returned to regular session. There were no decisions or votes taken except to return to regular session and any information shared during the Executive Session is privileged and needs to remain in Executive Session. F. Proposed Vote to Approve or Disapprove the Medical Executive Committee Recommendations Regarding Credentialing of the Referenced Medical Staff Members as Listed in XII B 1-3 ACTION TAKEN: Mr. Weber motioned to approve credentialing items as recommended by Medical Executive Committee and Credentials Committee of all referenced Medical Staff members listed in XII B 1-3. Dr. Anwar seconded, and the motion was approved with unanimous aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts.  NRHA Board Minutes 9 October 23, 2023 Agenda Item XIV. Board Open Discussion Mr. Chappel, Ms. Womack and Dr. Weber provided their individual perspectives related to their recent attendance of the Vizient CEO & Trustees Networking Conference held in San Antonio, TX. The trustees attended general education sessions providing roundtable dialogue, networking opportunities and insight into innovations and strategies critical in today’s rapidly and ever-changing healthcare industry. Agenda Item XV. Adjournment ACTION TAKEN: Dr. Weber made a motion to adjourn the meeting at 7:41pm. Dr. Anwar seconded, and the motion passed unanimously with aye votes from Mr. Cubberley, Ms. Greenleaf, Mr. Chappel, Dr. Weber, Dr. Anwar, Ms. Womack and Ms. Roberts. Respectfully Submitted, Mary Womack, Vice-Chair/Secretary